A. Disorders of the musculoskeletal
system may result from hereditary, congenital, or acquired pathologic
processes. Impairments may result from infectious, inflammatory,
or degenerative processes, traumatic or developmental events, or
neoplastic, vascular, or toxic/metabolic diseases.

B. Loss of function.

1. General. Under this section, loss of function may be due to bone or joint deformity or destruction from any cause; miscellaneous disorders of the spine with or without radiculopathy or other neurological deficits; amputation; or fractures or soft tissue injuries, including burns, requiring prolonged periods of immobility or convalescence. The provisions of 1.02 and 1.03 notwithstanding, inflammatory arthritis is evaluated under 14.09 (see 14.00D6). Impairments with neurological causes are to be evaluated under 11.00ff.

2. How we define loss of function
in these listings.

a. General. Regardless of the
cause(s) of a musculoskeletal impairment, functional loss for purposes
of these listings is defined as the inability to ambulate effectively
on a sustained basis for any reason, including pain associated with
the underlying musculoskeletal impairment, or the inability to perform
fine and gross movements effectively on a sustained basis for any
reason, including pain associated with the underlying musculoskeletal
impairment. The inability to ambulate effectively or the inability
to perform fine and gross movements effectively must have lasted,
or be expected to last, for at least 12 months. For the purposes
of these criteria, consideration of the ability to perform these
activities must be from a physical standpoint alone. When there
is an inability to perform these activities due to a mental impairment,
the criteria in 12.00ff are to be used. We will determine whether
an individual can ambulate effectively or can perform fine and gross
movements effectively based on the medical and other evidence in
the case record, generally without developing additional evidence
about the individual's ability to perform the specific activities
listed as examples in 1.00B2b(2) and 1.00B2c.

b. What we mean by inability
to ambulate effectively.

(1) Definition. Inability to
ambulate effectively means an extreme limitation of the ability
to walk; i.e., an impairment(s) that interferes very seriously with
the individual's ability to independently initiate, sustain, or
complete activities. Ineffective ambulation is defined generally
as having insufficient lower extremity functioning (see 1.00J) to
permit independent ambulation without the use of a hand-held assistive
device(s) that limits the functioning of both upper extremities.
(Listing 1.05C is an exception to this general definition because
the individual has the use of only one upper extremity due to amputation
of a hand.)

(2) To ambulate effectively,
individuals must be capable of sustaining a reasonable walking pace
over a sufficient distance to be able to carry out activities of
daily living. They must have the ability to travel without companion
assistance to and from a place of employment or school. Therefore,
examples of ineffective ambulation include, but are not limited
to, the inability to walk without the use of a walker, two crutches
or two canes, the inability to walk a block at a reasonable pace
on rough or uneven surfaces, the inability to use standard public
transportation, the inability to carry out routine ambulatory activities,
such as shopping and banking, and the inability to climb a few steps
at a reasonable pace with the use of a single hand rail. The ability
to walk independently about one's home without the use of assistive
devices does not, in and of itself, constitute effective ambulation.

c. What we mean by inability
to perform fine and gross movements effectively. Inability to perform
fine and gross movements effectively means an extreme loss of function
of both upper extremities; i.e., an impairment(s) that interferes
very seriously with the individual's ability to independently initiate,
sustain, or complete activities. To use their upper extremities
effectively, individuals must be capable of sustaining such functions
as reaching, pushing, pulling, grasping, and fingering to be able
to carry out activities of daily living. Therefore, examples of
inability to perform fine and gross movements effectively include,
but are not limited to, the inability to prepare a simple meal and
feed oneself, the inability to take care of personal hygiene, the
inability to sort and handle papers or files, and the inability
to place files in a file cabinet at or above waist level.

d. Pain or other symptoms. Pain
or other symptoms may be an important factor contributing to functional
loss. In order for pain or other symptoms to be found to affect
an individual's ability to perform basic work activities, medical
signs or laboratory findings must show the existence of a medically
determinable impairment(s) that could reasonably be expected to
produce the pain or other symptoms. The musculoskeletal listings
that include pain or other symptoms among their criteria also include
criteria for limitations in functioning as a result of the listed
impairment, including limitations caused by pain. It is, therefore,
important to evaluate the intensity and persistence of such pain
or other symptoms carefully in order to determine their impact on
the individual's functioning under these listings. See also §§ 404.1525(f)
and 404.1529 of this part, and §§ 416.925(f) and 416.929 of
part 416 of this chapter.

C. Diagnosis and evaluation.

1. General. Diagnosis and evaluation
of musculoskeletal impairments should be supported, as applicable,
by detailed descriptions of the joints, including ranges of motion,
condition of the musculature (e.g., weakness, atrophy), sensory
or reflex changes, circulatory deficits, and laboratory findings,
including findings on x-ray or other appropriate medically acceptable
imaging. Medically acceptable imaging includes, but is not limited
to, x-ray imaging, computerized axial tomography (CAT scan)
or magnetic resonance imaging (MRI), with or without contrast material,
myelography, and radionuclear bone scans. "Appropriate"
means that the technique used is the proper one to support the evaluation
and diagnosis of the impairment.

2. Purchase of certain medically
acceptable imaging. While any appropriate medically acceptable imaging
is useful in establishing the diagnosis of musculoskeletal impairments,
some tests, such as CAT scans and MRIs, are quite expensive, and
we will not routinely purchase them. Some, such as myelograms, are
invasive and may involve significant risk. We will not order such
tests. However, when the results of any of these tests are part
of the existing evidence in the case record we will consider them
together with the other relevant evidence.

3. Consideration of electrodiagnostic
procedures. Electrodiagnostic procedures may be useful in establishing
the clinical diagnosis, but do not constitute alternative criteria
to the requirements of 1.04.

D. The physical examination
must include a detailed description of the rheumatological, orthopedic,
neurological, and other findings appropriate to the specific impairment
being evaluated. These physical findings must be determined on the
basis of objective observation during the examination and not simply
a report of the individual's allegation; e.g., "He says his
leg is weak, numb." Alternative testing methods should be used
to verify the abnormal findings; e.g., a seated straight-leg raising
test in addition to a supine straight-leg raising test. Because
abnormal physical findings may be intermittent, their presence over
a period of time must be established by a record of ongoing management
and evaluation. Care must be taken to ascertain that the reported
examination findings are consistent with the individual's daily
activities.

E. Examination of the spine.

1. General. Examination of the
spine should include a detailed description of gait, range of motion
of the spine given quantitatively in degrees from the vertical position
(zero degrees) or, for straight-leg raising from the sitting
and supine position (zero degrees), any other appropriate tension
signs, motor and sensory abnormalities, muscle spasm, when present,
and deep tendon reflexes. Observations of the individual during
the examination should be reported; e.g., how he or she gets on
and off the examination table. Inability to walk on the heels or
toes, to squat, or to arise from a squatting position, when appropriate,
may be considered evidence of significant motor loss. However, a
report of atrophy is not acceptable as evidence of significant motor
loss without circumferential measurements of both thighs and lower
legs, or both upper and lower arms, as appropriate, at a stated
point above and below the knee or elbow given in inches or centimeters.
Additionally, a report of atrophy should be accompanied by measurement
of the strength of the muscle(s) in question generally based on
a grading system of 0 to 5 , with 0 being complete loss of strength
and 5 being maximum strength. A specific description of atrophy
of hand muscles is acceptable without measurements of atrophy but
should include measurements of grip and pinch strength.

2. When neurological abnormalities
persist. Neurological abnormalities may not completely subside after
treatment or with the passage of time. Therefore, residual neurological
abnormalities that persist after it has been determined clinically
or by direct surgical or other observation that the ongoing or progressive
condition is no longer present will not satisfy the required findings
in 1.04. More serious neurological deficits (paraparesis, paraplegia)
are to be evaluated under the criteria in 11.00ff.

F. Major joints refers to the
major peripheral joints, which are the hip, knee, shoulder, elbow,
wrist-hand, and ankle-foot, as opposed to other peripheral joints
(e.g., the joints of the hand or forefoot) or axial joints (i.e.,
the joints of the spine.) The wrist and hand are considered together
as one major joint, as are the ankle and foot. Since only the ankle
joint, which consists of the juncture of the bones of the lower
leg (tibia and fibula) with the hindfoot (tarsal bones), but not
the forefoot, is crucial to weight bearing, the ankle and foot are
considered separately in evaluating weight bearing.

G. Measurements of joint motion
are based on the techniques described in the chapter on the extremities,
spine, and pelvis in the current edition of the "Guides to
the Evaluation of Permanent Impairment" published by the American
Medical Association.

H. Documentation.

1. General. Musculoskeletal
impairments frequently improve with time or respond to treatment.
Therefore, a longitudinal clinical record is generally important
for the assessment of severity and expected duration of an impairment
unless the claim can be decided favorably on the basis of the current
evidence.

2. Documentation of medically
prescribed treatment and response. Many individuals, especially
those who have listing-level impairments, will have received the
benefit of medically prescribed treatment. Whenever evidence of
such treatment is available it must be considered.

3. When there is no record of
ongoing treatment. Some individuals will not have received ongoing
treatment or have an ongoing relationship with the medical community
despite the existence of a severe impairment(s). In such cases,
evaluation will be made on the basis of the current objective medical
evidence and other available evidence, taking into consideration
the individual's medical history, symptoms, and medical source opinions.
Even though an individual who does not receive treatment may not
be able to show an impairment that meets the criteria of one of
the musculoskeletal listings, the individual may have an impairment(s)
equivalent in severity to one of the listed impairments or be disabled
based on consideration of his or her residual functional capacity
(RFC) and age, education and work experience.

4. Evaluation when the criteria
of a musculoskeletal listing are not met. These listings are only
examples of common musculoskeletal disorders that are severe enough
to prevent a person from engaging in gainful activity. Therefore,
in any case in which an individual has a medically determinable
impairment that is not listed, an impairment that does not meet
the requirements of a listing, or a combination of impairments no
one of which meets the requirements of a listing, we will consider
medical equivalence. (See §§ 404.1526 and 416.926.) Individuals
who have an impairment(s) with a level of severity that does not
meet or equal the criteria of the musculoskeletal listings may or
may not have the RFC that would enable them to engage in substantial
gainful activity. Evaluation of the impairment(s) of these individuals
should proceed through the final steps of the sequential evaluation
process in §§ 404.1520 and 416.920 (or, as appropriate, the
steps in the medical improvement review standard in §§ 404.1594
and 416.994).

I. Effects of treatment.

1. General. Treatments for musculoskeletal
disorders may have beneficial effects or adverse side effects. Therefore,
medical treatment (including surgical treatment) must be considered
in terms of its effectiveness in ameliorating the signs, symptoms,
and laboratory abnormalities of the disorder, and in terms of any
side effects that may further limit the individual.

2. Response to treatment. Response
to treatment and adverse consequences of treatment may vary widely.
For example, a pain medication may relieve an individual's pain
completely, partially, or not at all. It may also result in adverse
effects, e.g., drowsiness, dizziness, or disorientation, that compromise
the individual's ability to function. Therefore, each case must
be considered on an individual basis, and include consideration
of the effects of treatment on the individual's ability to function.

3. Documentation. A specific
description of the drugs or treatment given (including surgery),
dosage, frequency of administration, and a description of the complications
or response to treatment should be obtained. The effects of treatment
may be temporary or long-term. As such, the finding regarding the
impact of treatment must be based on a sufficient period of treatment
to permit proper consideration or judgment about future functioning.

J. Orthotic, prosthetic, or
assistive devices.

1. General. Consistent with
clinical practice, individuals with musculoskeletal impairments
may be examined with and without the use of any orthotic, prosthetic,
or assistive devices as explained in this section.

2. Orthotic devices. Examination
should be with the orthotic device in place and should include an
evaluation of the individual's maximum ability to function effectively
with the orthosis. It is unnecessary to routinely evaluate the individual's
ability to function without the orthosis in place. If the individual
has difficulty with, or is unable to use, the orthotic device, the
medical basis for the difficulty should be documented. In such cases,
if the impairment involves a lower extremity or extremities, the
examination should include information on the individual's ability
to ambulate effectively without the device in place unless contraindicated
by the medical judgment of a physician who has treated or examined
the individual.

3. Prosthetic devices. Examination
should be with the prosthetic device in place. In amputations involving
a lower extremity or extremities, it is unnecessary to evaluate
the individual's ability to walk without the prosthesis in place.
However, the individual's medical ability to use a prosthesis to
ambulate effectively, as defined in 1.00B2b, should be evaluated.
The condition of the stump should be evaluated without the prosthesis
in place.

4. Hand-held assistive devices.
When an individual with an impairment involving a lower extremity
or extremities uses a hand-held assistive device, such as a cane,
crutch or walker, examination should be with and without the use
of the assistive device unless contraindicated by the medical judgment
of a physician who has treated or examined the individual. The individual's
ability to ambulate with and without the device provides information
as to whether, or the extent to which, the individual is able to
ambulate without assistance. The medical basis for the use of any
assistive device (e.g., instability, weakness) should be documented.
The requirement to use a hand-held assistive device may also impact
on the individual's functional capacity by virtue of the fact that
one or both upper extremities are not available for such activities
as lifting, carrying, pushing, and pulling.

K. Disorders of the spine, listed
in 1.04, result in limitations because of distortion of the bony
and ligamentous architecture of the spine and associated impingement
on nerve roots (including the cauda equina) or spinal cord.
Such impingement on nerve tissue may result from a herniated nucleus
pulposus, spinal stenosis, arachnoiditis, or other miscellaneous
conditions.

1. Herniated nucleus pulposus
is a disorder frequently associated with the impingement of a nerve
root. Nerve root compression results in a specific neuro-anatomic
distribution of symptoms and signs depending upon the nerve root(s)
compromised.

2. Spinal arachnoiditis.

a. General. Spinal arachnoiditis
is a condition characterized by adhesive thickening of the arachnoid
which may cause intermittent ill-defined burning pain and sensory
dysesthesia, and may cause neurogenic bladder or bowel incontinence
when the cauda equina is involved.

b. Documentation. Although the
cause of spinal arachnoiditis is not always clear, it may be associated
with chronic compression or irritation of nerve roots (including
the cauda equina) or the spinal cord. For example, there may be
evidence of spinal stenosis, or a history of spinal trauma or meningitis.
Diagnosis must be confirmed at the time of surgery by gross description,
microscopic examination of biopsied tissue, or by findings on appropriate
medically acceptable imaging. Arachnoiditis is sometimes used as
a diagnosis when such a diagnosis is unsupported by clinical or
laboratory findings. Therefore, care must be taken to ensure that
the diagnosis is documented as described in 1.04B. Individuals with
arachnoiditis, particularly when it involves the lumbosacral spine,
are generally unable to sustain any given position or posture for
more than a short period of time due to pain.

3. Lumbar spinal stenosis is
a condition that may occur in association with degenerative processes,
or as a result of a congenital anomaly or trauma, or in association
with Paget's disease of the bone. Pseudoclaudication, which
may result from lumbar spinal stenosis, is manifested as pain and
weakness, and may impair ambulation. Symptoms are usually bilateral,
in the low back, buttocks, or thighs, although some individuals
may experience only leg pain and, in a few cases, the leg pain may
be unilateral. The pain generally does not follow a particular neuro-anatomical
distribution, i.e., it is distinctly different from the radicular
type of pain seen with a herniated intervertebral disc, is often
of a dull, aching quality, which may be described as "discomfort"
or an "unpleasant sensation," or may be of even greater
severity, usually in the low back and radiating into the buttocks
region bilaterally. The pain is provoked by extension of the spine,
as in walking or merely standing, but is reduced by leaning forward.
The distance the individual has to walk before the pain comes on
may vary. Pseudoclaudication differs from peripheral vascular claudication
in several ways. Pedal pulses and Doppler examinations are unaffected
by pseudoclaudication. Leg pain resulting from peripheral vascular
claudication involves the calves, and the leg pain in vascular claudication
is ordinarily more severe than any back pain that may also be present.
An individual with vascular claudication will experience pain after
walking the same distance time after time, and the pain will be
relieved quickly when walking stops.

4. Other miscellaneous conditions
that may cause weakness of the lower extremities, sensory changes,
areflexia, trophic ulceration, bladder or bowel incontinence, and
that should be evaluated under 1.04 include, but are not limited
to, osteoarthritis, degenerative disc disease, facet arthritis,
and vertebral fracture. Disorders such as spinal dysrhaphism (e.g.,
spina bifida), diastematomyelia, and tethered cord syndrome may
also cause such abnormalities. In these cases, there may be gait
difficulty and deformity of the lower extremities based on neurological
abnormalities, and the neurological effects are to be evaluated
under the criteria in 11.00ff.

L. Abnormal curvatures of the
spine. Abnormal curvatures of the spine (specifically, scoliosis,
kyphosis and kyphoscoliosis) can result in impaired ambulation,
but may also adversely affect functioning in body systems other
than the musculoskeletal system. For example, an individual's ability
to breathe may be affected; there may be cardiac difficulties (e.g.,
impaired myocardial function); or there may be disfigurement resulting
in withdrawal or isolation. When there is impaired ambulation, evaluation
of equivalence may be made by reference to 14.09A. When the abnormal
curvature of the spine results in symptoms related to fixation of
the dorsolumbar or cervical spine, evaluation of equivalence may
be made by reference to 14.09C. When there is respiratory or cardiac
involvement or an associated mental disorder, evaluation may be
made under 3.00ff, 4.00ff, or 12.00ff, as appropriate. Other consequences
should be evaluated according to the listing for the affected body
system.

M. Under continuing surgical
management, as used in 1.07 and 1.08, refers to surgical procedures
and any other associated treatments related to the efforts directed
toward the salvage or restoration of functional use of the affected
part. It may include such factors as post-surgical procedures, surgical
complications, infections, or other medical complications, related
illnesses, or related treatments that delay the individual's attainment
of maximum benefit from therapy. When burns are not under continuing
surgical management, see 8.00F.

N. After maximum benefit from
therapy has been achieved in situations involving fractures of an
upper extremity (1.07), or soft tissue injuries (1.08), i.e., there
have been no significant changes in physical findings or on appropriate
medically acceptable imaging for any 6-month period after the last
definitive surgical procedure or other medical intervention, evaluation
must be made on the basis of the demonstrable residuals, if any.
A finding that 1.07 or 1.08 is met must be based on a consideration
of the symptoms, signs, and laboratory findings associated with
recent or anticipated surgical procedures and the resulting recuperative
periods, including any related medical complications, such as infections,
illnesses, and therapies which impede or delay the efforts toward
restoration of function. Generally, when there has been no surgical
or medical intervention for 6 months after the last definitive
surgical procedure, it can be concluded that maximum therapeutic
benefit has been reached. Evaluation at this point must be made
on the basis of the demonstrable residual limitations, if any, considering
the individual's impairment-related symptoms, signs, and laboratory
findings, any residual symptoms, signs, and laboratory findings
associated with such surgeries, complications, and recuperative
periods, and other relevant evidence.

O. Major function of the face
and head, for purposes of listing 1.08, relates to impact on
any or all of the activities involving vision, hearing, speech,
mastication, and the initiation of the digestive process.

P. When surgical procedures
have been performed, documentation should include a copy of the
operative notes and available pathology reports.

Q. Effects of obesity. Obesity
is a medically determinable impairment that is often associated
with disturbance of the musculoskeletal system, and disturbance
of this system can be a major cause of disability in individuals
with obesity. The combined effects of obesity with musculoskeletal
impairments can be greater than the effects of each of the impairments
considered separately. Therefore, when determining whether an individual
with obesity has a listing-level impairment or combination of impairments,
and when assessing a claim at other steps of the sequential evaluation
process, including when assessing an individual's residual functional
capacity, adjudicators must consider any additional and cumulative
effects of obesity.

1.02 Major
dysfunction of a joint(s) (due to any cause): Characterized
by gross anatomical deformity (e.g., subluxation, contracture, bony
or fibrous ankylosis, instability) and chronic joint pain and stiffness
with signs of limitation of motion or other abnormal motion of the
affected joint(s), and findings on appropriate medically acceptable
imaging of joint space narrowing, bony destruction, or ankylosis
of the affected joint(s). With:

A. Involvement of one major
peripheral weight-bearing joint (i.e., hip, knee, or ankle), resulting
in inability to ambulate effectively, as defined in 1.00B2b;

OR

B. Involvement of one major
peripheral joint in each upper extremity (i.e., shoulder, elbow,
or wrist-hand), resulting in inability to perform fine and gross
movements effectively, as defined in 1.00B2c.

1.03 Reconstructive surgery or surgical arthrodesis of a major
weight- bearing joint, with inability to ambulate
effectively, as defined in 1.00B2b, and return to effective ambulation
did not occur, or is not expected to occur, within 12 months
of onset.

A. Evidence of nerve root compression
characterized by neuro-anatomic distribution of pain, limitation
of motion of the spine, motor loss (atrophy with associated muscle
weakness or muscle weakness) accompanied by sensory or reflex loss
and, if there is involvement of the lower back, positive straight-leg
raising test (sitting and supine);

OR

B. Spinal arachnoiditis, confirmed
by an operative note or pathology report of tissue biopsy, or by
appropriate medically acceptable imaging, manifested by severe burning
or painful dysesthesia, resulting in the need for changes in position
or posture more than once every 2 hours;

or

C. Lumbar spinal stenosis resulting
in pseudoclaudication, established by findings on appropriate medically
acceptable imaging, manifested by chronic nonradicular pain and
weakness, and resulting in inability to ambulate effectively, as
defined in 1.00B2b.

B. One or both lower extremities
at or above the tarsal region, with stump complications resulting
in medical inability to use a prosthetic device to ambulate effectively,
as defined in 1.00B2b, which have lasted or are expected to last
for at least 12 months;

or

C. One hand and one lower extremity
at or above the tarsal region, with inability to ambulate effectively,
as defined in 1.00B2b;

1.07 Fracture of an upper extremity with nonunion of
a fracture of the shaft of the humerus, radius, or ulna, under continuing
surgical management, as defined in 1.00M, directed toward restoration
of functional use of the extremity, and such function was not restored
or expected to be restored within 12 months of onset.

1.08 Soft
tissue injury (e.g., burns) of an upper or lower extremity,
trunk, or face and head, under continuing surgical management, as
defined in 1.00M, directed toward the salvage or restoration of
major function, and such major function was not restored or expected
to be restored within 12 months of onset. Major function of
the face and head is described in 1.00.